Before conception

Glycemic control

Risk is lowest if HbA1c levels are ≤ 6.5% at conception.†

Evaluation includes

• Complete metabolic panel and a 24-hour urine collection (protein excretion and creatinine clearance) or spot urine protein:creatinine ratio to check for nephropathy

• Ophthalmologic examination to check for retinopathy

• ECG to check for cardiac complications

Prenatal

Prenatal visits begin as soon as pregnancy is confirmed.

Frequency of visits is determined by degree of glycemic control.

Diet should be individualized according to ADA guidelines and coordinated with insulin administration.

Three meals and three snacks/day are recommended, with emphasis on consistent timing.

Women are instructed in and should do blood glucose self-monitoring.

Women should be cautioned about the dangers of hypoglycemia during exercise and at night.

HbA1c level should be checked every trimester.

Antenatal testing with the following should be done from 32 weeks to delivery (or earlier if indicated):

• Nonstress tests (weekly)

• Biophysical profiles (weekly)

• Kick counts (daily)

Amount and type of insulin should be individualized. In the morning, two thirds of the total dose (60% NPH, 40% regular) is taken; in the evening one third (50% NPH, 50% regular) is taken. Or, women can take long-acting insulin once or twice a day and insulin aspart immediately before breakfast, lunch, and dinner.‡

During labor and delivery

Vaginal delivery at term is possible if women have documented dating criteria and good glycemic control.

Cesarean delivery should be reserved for obstetric indications or fetal macrosomia (> 4500 g), which increases risk of shoulder dystocia.

The optimal timing of delivery relies on balancing the risk of fetal death with the risks of preterm birth. Early delivery (36 to38 6/7 weeks of gestation, or even earlier) may be indicated in some patients with complications such as, vasculopathy, nephropathy, poor glucose control, or a prior stillbirth. Women with well-controlled diabetes with no other comorbidities may be managed expectantly to 39 0/7 weeks to 39 6/7 weeks of gestation as long as antenatal testing remains reassuring.

During delivery, a constant low-dose insulin infusion is usually preferred, and the usual subcutaneous administration of insulin is stopped. If induction is planned, the usual evening long-acting insulin dose is given on the day before induction.

Postpartum and continuing diabetes care should be arranged.

Postpartum insulin requirements may decrease by up to 50%.